C H A P T E R

5
Pneumocephalus
Hemanshu Prabhakar, Parmod K. Bithal
Department of Neuroanaesthesiology and Critical Care, All India Institute
of Medical Sciences, New Delhi, India

O U T L I N E

Definition35
Variant36
Cause36
Signs and Symptoms 36
Diagnosis37
Predisposing Factors 37
Treatment38
Prevention38
References39

DEFINITION
Pneumocephalus is defined as an asymptomatic intracranial collection
of air, commonly occurring after craniotomy or cranial burr hole. In a ret-
rospective study, the incidence of intracranial air collection varied from
73% in park-bench position, 57% in prone position, and 100% in sitting
position.1 Clinical data on the retrospective review of CT scans indicate

Complications in Neuroanesthesia 35
http://dx.doi.org/10.1016/B978-0-12-804075-1.00005-5 © 2016 Elsevier Inc. All rights reserved.
36 5. PNEUMOCEPHALUS

that all patients have pneumocephalus in the first 2 days after a supraten-
torial craniotomy.2

VARIANT

Occasionally, high pressure may build up in the air cavity, which results
in the development of “tension pneumocephalus,” or “inverted pop-up
bottle” syndrome. Tension pneumocephalus is, therefore, air in the intra-
cranial compartment that is under pressure and requires immediate
evacuation.

CAUSE

The collection of air in the cranial vault is either due to drainage of

cerebrospinal fluid, or due to venous blood moving out of the cranium, as
in the sitting position, which reduces the brain bulk. Similarly, intraopera-
tive hyperventilation shrinks the brain secondary to hypocapnia. All this
creates room for the air to collect, and if not corrected at the end of the
procedure, pneumocephalus develops. Some of the common causes for
the development of pneumocephalus include the following:
  

1. Recent craniotomy or craniectomy3

2. Prolonged surgery in sitting position
3. Following awake craniotomy
4. Trauma, skull-base fracture, fracture of the skull with laceration of
dura
5. Infection, with gas-forming organisms, such as mastoiditis
6. After ventriculostomy
7. Spinal or epidural anesthesia
8. Following surgery on the spine
9. Intravenous catheterization (rarely)
10. Spontaneous pneumocephalus4
11. Positive pressure mask ventilation in postoperative patients of
transsphenoidal pituitary surgery5
12. Use of drugs such as Cabergoline6

SIGNS AND SYMPTOMS

Some of the common signs and symptoms are as follows:

  

1. D  eterioration of consciousness with or without lateralizing signs

2. Severe restlessness

I.  COMPLICATIONS RELATED TO THE BRAIN

 Predisposing Factors 37

3. G  eneralized convulsions
4. D  elayed recovery from anesthesia
5. Arterial hypertension and reflex bradycardia

DIAGNOSIS

The diagnosis of pneumocephalus can be made clinically based on a

high index of suspicion. However, a computed tomographic scan can eas-
ily diagnose pneumocephalus (Figure 1). The intracranial gas may also be
detected by a plain X-ray of the skull. Mt. Fuji sign is very characteristic of
pneumocephalus, especially if it is located bilaterally. The sign is charac-
terized by the peaked frontal lobes, which are surrounded and separated
by air.

PREDISPOSING FACTORS

Several contributing factors have been implicated in the pathogenesis of

pneumocephalus, producing tension effect: nitrous oxide anesthesia, dura-
tion of surgery, gross hydrocephalus, a functional ventriculoperitoneal

FIGURE 1  A computed tomographic scan showing a large collection of air (bold white
arrow).

I.  COMPLICATIONS RELATED TO THE BRAIN

38 5. PNEUMOCEPHALUS

BOX 1

Factors contributing to development of tension pneumocephalus.

  

1.  itrous oxide anesthesia

N
2. Duration of surgery
3. Gross hydrocephalus
4. Presence of a functional ventriculoperitoneal shunt
5. Intraoperative mannitol or furosemide administration
6. Size of air cavity
7. Surgical position of patient (always observed in sitting position)
8. Head position after surgery

shunt, intraoperative mannitol or furosemide administration, size of the

air cavity, surgical position of the patient, and position of the head after
surgery (Box 1).

TREATMENT

In majority of the cases, pneumocephalus is asymptomatic and requires

conservative treatment. In the absence of leaking cerebrospinal fluid, the
entrapped air gradually gets absorbed and the pneumocephalus resolves.
However, treatment of the primary cause may be essential, especially
if pneumocephalus is due to gas-forming organisms. Appropriate anti-
biotics may be started for control of infection. During the postopera-
tive period, pneumocephalus may be treated by pure oxygen through a
face mask that facilitates resorption and prevents desaturation in case of
breathing difficulties.
Active intervention is needed in cases of tension pneumocephalus. An
emergent frontal twist drill burr hole aspiration of pneumocephalus pro-
ducing significant symptoms is the treatment of choice. A clinically sig-
nificant improvement is seen following burr hole evacuation.

PREVENTION
To prevent the development of pneumocephalus, efforts must be
directed at minimizing loss of cerebrospinal fluid, maintaining adequate
hydration for proper cerebral perfusion, and allowing the brain to regain
its normal contour by bringing the end-tidal carbon dioxide to normal
levels toward the end of surgery. Subdural injection of saline to displace

I.  COMPLICATIONS RELATED TO THE BRAIN

 References 39

the residual air may also be useful. Prompt detection of the intracranial
hypertension caused by tension pneumocephalus is aided by intracranial
pressure monitoring. However, the benefits of intracranial pressure moni-
toring in the immediate postoperative period must be weighed against the
associated risks and complications.

References
1. Toung TJ, McPherson RW, Ahn H, Donham RT, Alano J, Long D. Pneumocephalus:
effects of patient position on the incidence and location of aerocele after posterior fossa
and upper cervical cord surgery. Anesth Analg. 1986;65:65–70.
2. Reasoner DK, Todd MM, Scamman FL, Warner DS. The incidence of pneumocephalus
after supratentotial craniotomy. Observations on the disappearance of intracranial air.
Anesthesiology. 1994;80:1008–1012.
3. Prabhakar H, Bithal PK, Garg A. Tension pneumocephalus after craniotomy in supine
position. J Neurosurg Anesthesiol. 2003;15:278–281.
4. Nash R, Wilson M, Adams M, Kitchen N. Spontaneous pneumocephalus presenting with
alien limb phenomena. J Laryngol Otol. 2012;126:733–736.
5. Kopelovich JC, de la Garza GO, Greenlee JD, Graham SM, Udeh CI, O’Brien EK. Pneumo-
cephalus with BiPAP use after transsphenoidal surgery. J Clin Anesth. 2012;24:415–418.
6. Machicado JD, Varghese JM, Orlander PR. Cabergoline-induced pneumocephalus in a
medically treated macroprolactinoma. J Clin Endocrinol Metab. 2012;97:3412–3413.

I.  COMPLICATIONS RELATED TO THE BRAIN